Appropriate use of anabolic treatment for severe osteoporosis

Osteoporotic fractures remain a major public health problem for their correlated morbidity and mortality. The primary aim of therapy must be the prevention of the first fragility fracture and avoiding subsequent fractures in patients who already have an existing fracture. There are evidences from randomized controlled trials (RCTs) about the efficacy of antiresorptives, such as bisphosphonates in reducing the risk of fracture, but none of these agents completely abolish the fracture risk. The reduction of RRR by different therapies in RCTs is relatively constant but it is important to note that the proportion of inadequate-responders (i.e.: patients fracturing despite adequate pharmacological treatment) is increasing with the severity of the disease: the higher the risk of fracture the higher the proportion of inadequate-responders. Thus, the proportion of non responders across different trials is directly related to the fracture incidence observed in the control group of RCTs which is the most proximate indicator of osteoporosis severity. Teriparatide (TPTD) demonstrate a real increases of both trabecular and cortical bone volume, which are associated with a true reduction of fracture risk, as many RCTs confirm. The beneficial effect of introducing a treatment with antiresorptives after the treatment course with TPTD has been clearly demonstrated with the prevention of the reabsorption of the new bone tissue built during TPTD therapy and rapidly lowers cortical porosity, which leads to further increases in BMD. For these results, the introduction of an anti-resorptive after the treatment course with TPTD is strongly recommended and taken into account. In Italy TPTD is fully reimbursed in patients incurring in a new vertebral or hip fracture while on chronic treatment with antiresorptive or in naive patients with 3 or more vertebral or hip fractures. In conclusion, since patients with severe osteoporosis are at very high risk of new fractures with worsening of quality of life and life expectancy, antiresorptives represent a sub-optimal treatment in these patients, werehas, since TPTD demonstrated real and substantial improvements in bone mass and reduction of fracture risk independently of initial risk, TPTD represents the only therapeutic option able to reverse at least in part this disabling disease.